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.fig ,.� ..M��. Y �.1e•'--•✓pp�,, '..- - - _ _ �•.S MY...-. S. .Ft-:`�_�i.• <br /> � �- �,.k,�0.�`i J is•- �T�:. S':''C.i•:fya-r ;,r c_� <br /> JOB KESS: <br /> ADD <br /> _ a•,;,.;' <br /> KIWIt S0* <br /> LICENSED CONTRACTORS DECLARATION (I.CD) <br /> 1 hereby atm that i am licensed under the provision of Chapter 9(commencing with Section 7000 of Division <br /> 3 of the Business and Professions Code)and my Manse is in fun force and effect <br /> LlcensaiF �� [ I ExpirationDatr. Mitt-31�. 2vo <br /> Date._OC r Zrj�,20D l Contract r. <br /> Sf9natttre: r Title: <br /> Pare na <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of.the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certifiatQ of consent to self-Insure for workers'compensation, as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. <br /> ✓ t have and will maintain workers'compensaton insurance, as required by Sedion 3700 of the Labor Code, <br /> for the performance of the work for which this permit is Issued. My workers'compensation Insurance <br /> carrier and policy numbers are: <br /> Carrier:t�fLh✓arL+t+�3 �^35 Policy Number. V/46 X9g(K s-6 47 <br /> ZI certify that in the performance of the work for which this permit is issued, I shell not employ any person In <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that N I <br /> should become subject to the workers' compensation provisions of Secllort 3700 of the Labor Code,l shall <br /> forthwith comply with those provisions. <br /> Date- GLT- 23� �Signature: TC4 <br /> Printed Name: r► <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> Ali EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ) FOR N ADDITION <br /> T THE COST OF OF THP IE COM ENSATEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PftoVfUE4 <br /> L f ru C (C-57)lcanae holder),hereby <br /> . authorha '� or ¢V nJ o ` i Q�co'ulting),to sign this San <br /> Joaquin County Well Permit Application on my behalf. t understand this authorization is vatld for one(1)year <br /> and i5 limited to the work Plan dated on the front page of thin apPliratfenr <br /> i <br /> 'l <br />